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Important information about why your OT is eyebrow deep in paperwork

How would you like to wake up one morning and find out that there are new rules you need to know in order to get your paycheck at the end of the week? Those of us who work in private practice understand that the rules for reimbursement change and shift constantly, but imagine wading through hundreds of pages in the hopes of trying to find the tidbits that actually apply to what you are supposed to be doing. Enjoy this link for some light reading: Medicare Physician Fee Schedule Final Rule CY 2013 . These requirements were just recently published and significantly change the coding requirements for Medicare reimbursement. Again.

Other changes that we have this week are more wonderful rules to contend with - this time having to do with complex requirements for what a physician's referral has to say in order for a school district to bill related services under the Medicaid program. This NYS Medicaid rule set is not as long as the CMS rules but only covers a very small component of service (what MD scripts have to say) - but it is just as confusing. I like to think that I am at the least a moderately well educated person and in addition to my doctoral education I also have some measure of common sense - so why is it so challenging to wade through and try to understand these arbitrary rules? Here are the new NYS Medicaid requirements for scripts.

As you can see in the new Medicaid rules they initially tolerated certain language in scripts, then they expressly prohibited that language, and now they are back to accepting that language again (I think). These are small issues, actually, and have to do with whether or not a physician can write 'PER THE IEP' on a script or whether or not frequency, duration, and other factors need to be separately noted.

What is most frustrating is that with every rule change comes the accompanying threat (generally not even covert) that if you fail to follow the rules that you are committing Medicaid fraud. The friendly State reminds us in the memo:

18 NYCRR 515.2(b)(1)(c), Unacceptable practices under the medical assistance program, states that an unacceptable practice is conduct which constitutes fraud or abuse and includes submitting, or causing to be submitted, a claim or claims for medical care, services or supplies provided at a frequency or in an amount not medically necessary.

Now no one who is trying to figure out the new rules is purposely trying to commit fraud - but here is a case where there are two conflicting demands. Medicaid will not pay for a service that is beyond what is written on the script, but at the same time the State Education Department demands that all missed services be 'made up.' In fact, parents are legally entitled to compensatory services when absences or other events prevent a child from receiving the services on any given day. So, 'making up' services might cause you to try to see a child in a way that is not listed on the script because it might not be realistic to make up those services within the same week that they were missed. BOOM! Medicaid fraud - because as it stands now the reporting forms that we use to track service delivery are not separated and if the district attempts to bill for something that is different than the physician's script then you are now considered guilty of Medicaid fraud. It is truly a rock and a hard place.

The reason why this matters is because none of it has anything to do with the care that children receive - at least not in any direct sense. The rules are arbitrary, and they change, and they distract care providers from the important tasks that they SHOULD be focusing on.

So-called concierge models of care eliminate insurance companies and return relationships back to a normalized interaction between providers and the people who are seeking services. The legitimate criticism is that this model creates access barriers for people who do not have enough money to pay for services privately. Many medical practices are experimenting with hybrid models to address that criticism. When there are constant rule changes and complexities that create barriers to care these concierge models start to look very appealing, even though they have limitations.

Parents need to be aware of these kind of issues, which although might be superficially boring really do have an impact on the mindset of how care is provided within municipal systems and through complex health insurance rules. In my opinion there are probably less complex methods for solving these problems, but as we hand more and more control over health care to our government we can expect increasing points of arbitrary decision making, convoluted and conflicting recommendations, and in the end this will all create more barriers to quality care. As I tell my staff, be prepared for a bumpy ride.

Comments

It is frustrating that providers are so put upon by the regulations that it is easier to go to a policy of not accepting any insurances. It seems to be a theme that is recurring more and more. I'm still hopeful that things will get worked out in a way that provides better access for everyone, but I'm sure the change will still be difficult.

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Captain of the U.S.S. ABC Therapeutics - private practice near Buffalo, NY. Part time educator and full time stirrer of pots, happily responding to people's needs from deep within the "darkness of free enterprise."